Saddle pulmonary embolus with right heart strain

Case contributed by Dr Seamus O'Flaherty

Presentation

1 week of dyspnea on exertion progressing to dyspnea at rest.

Patient Data

Age: 60 years
Gender: Female

There is extensive central pulmonary embolus including a saddle embolus crossing the bifurcation of the pulmonary trunk. There is near occlusive embolus throughout the main pulmonary arteries bilaterally, slightly more extensive on the right.

On the right side there is occlusive embolus of upper lobar pulmonary arterial branches and partial occlusion of middle and lower lobar pulmonary arterial branches. 

Similarly, on the left side, there is occlusion of antero-apical segmental arteries to the left upper lobe, partial occlusion of the apical posterior segmental branches and occlusion of lingular branches. Partial occlusion of left lower lobar segmental pulmonary arterial branches. 

Right atrial and ventricular dilatation is evident along with contrast reflux into the IVC and straightening of the IV septum consistent with right heart strain. No pleural or pericardial effusion.  No pulmonary consolidation, collapse, region of hemorrhage or evolving infarction demonstrated. 

Bilateral axillary lymphadenopathy and upper anterior mediastinal lymphadenopathy is demonstrated.

Case Discussion

This is an interesting case of a previously well female patient who presented with progressive dyspnea of one week duration as her only symptom. By the time she presented to hospital she was in obstructive shock with evidence of acute right heart strain on CTPA and bedside echocardiogram. She received thrombolysis and then a heparin infusion and was stabilized. 

The CTPA revealed bilateral axillary and mediastinal lymphadenopathy. Further workup with CT abdomen-pelvis revealed bulky para-aortic nodes and a conglomerate mass in the left pelvis which was causing extrinsic compression of the common iliac vein with associated intraluminal thrombus. 

Lymph node biopsy diagnosed the patient with Lymphoma. This patient did not demonstrate any of the classic "B symptoms" of weight loss, night sweats or fever. 

She went on to receive treatment for her newly diagnosed lymphoma and did not have any significant sequelae from her extensive pulmonary emboli. 

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